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. Author manuscript; available in PMC: 2026 Jun 9.
Published in final edited form as: AIDS Behav. 2025 Jul 24;29(12):3866–3876. doi: 10.1007/s10461-025-04823-7

WeChat-based Messaging and Behavioral Counseling for Smoking Cessation for People with HIV in China: A Randomized Controlled Pilot Trial

Jiegang Huang 1,2,#, Shanyin Yang 3,#, Zhiman Xie 4, Baodong Guo 1,2, Yingji Lan 1,2, Yanjun Li 4, Yuan Jiang 5, Leah S Forman 6, Karsten Lunze 3, Bingyu Liang 1,2, Abu S Abdullah 3, Li Ye 2,7,8, Hao Liang 2,7,8,*, Lisa M Quintiliani 3,*
PMCID: PMC12858041  NIHMSID: NIHMS2131656  PMID: 40705206

Abstract

Cigarette smoking among people with HIV is a leading preventable cause of morbidity and mortality, particularly in China given its immense burden of smoking. This pilot study aimed to evaluate the feasibility, acceptability, and efficacy on smoking cessation of a community-informed WeChat-based messaging and behavioral counseling intervention for people with HIV who smoke called Quit for Life. The study design was a 2-group randomized clinical trial. Data collection occurred between February 2022 and August 2023 within a tertiary infectious disease hospital in Nanning city, Guangxi, China. Participants included adults with HIV who smoked, were willing to set a quit date, and received HIV care at the hospital. Participants were randomized to the 8-week Quit for Life intervention group (nicotine replacement therapy gum, self-help quitting smoking guide, behavioral counseling, and WeChat-based messaging), or the control group (nicotine replacement therapy gum and self-help guide only). Complete case analysis was performed. Of 219 people assessed for eligibility, 109 participants were randomized (mean [SD] age, 45.3 [15.1] years; men [96.3%]) and 98 completed the 12-week assessment (89.9% retention rate). At 12-week follow-up, the biochemically verified smoking cessation rate (primary outcome) was significantly higher in the intervention group compared to the control group (59.1% abstinence vs. 25.6%, adjusted odds ratio 5.3 [1.5,19.2]. Implementation and feasibility metrics indicated most participants receiving the intervention as intended gave high ratings of the usefulness of counseling sessions and WeChat-based messaging. Given these findings, subsequent studies should investigate implementation and scale-up of this intervention for people with HIV in China.

Keywords: HIV, smoking cessation, WeChat, behavioral counseling

INTRODUCTION

Tobacco smoking is highly prevalent in China, home to 1/3rd of the world’s total number of people who smoke.[1] The overall prevalence rate of tobacco smoking among all people over 15 years is estimated to be 24.7%, with much higher rates (47.7%) among males than among females (1.8%).[2] Among people with HIV (PWH) in China, the overall prevalence is even higher, with estimates of 51% from cross-sectional surveys in Beijing, Shanghai[3] and Guangxi.[4] Cigarette smoking among PWH is related to increased severity of HIV-related symptoms,[3] suboptimal antiretroviral therapy (ART) adherence[5], risk of chronic conditions (e.g., cardiovascular diseases, respiratory conditions, malignancies, negative neurological outcomes, and negative birth outcomes), and mortality compared to those without HIV who smoke.[6] Several factors point to the need for targeted interventions effective in helping PWH in low-to-middle income countries (LMICs) address their smoking, including differing health systems, workplace regulations, norms regarding smoking, and availability of cessation treatments.[7,8]

In a Cochrane review of tobacco use cessation interventions in PWH, all included trials took place in high income countries (primarily the U.S. and secondarily, Europe and Russia), with the exception of one study in South Africa[9]. Therefore, “there is an urgent need to develop, adapt, and implement effective tobacco control and cessation interventions targeted to [PWH] in LMICs”[7], notably China given its immense tobacco use burden. While trials of tobacco cessation among PWH in LMICs are on-going,[10,11] the Cochrane review[9] identified the present study as the only one taking place in China.

A body of literature[12] suggests that effective smoking cessation interventions among non-PWH populations in China include physician-delivered behavioral counseling[13] and those using digital health approaches such as mobile apps,[14] text and instant messaging using platforms such as WeChat and WhatsApp.[15–17] Based on this literature and our own formative research involving community members in Guangxi, China,[18] we developed a smoking cessation intervention specifically targeting PWH smokers there. The objective of this two-group, randomized controlled trial was to test the feasibility, acceptability, and efficacy[19] on 12-week biochemically-verified smoking abstinence of a smoking cessation intervention for PWH smokers in Guangxi, China called Quit for Life.

METHOD

Study design

In this two-group parallel randomized pilot trial with an additive design, participants were randomized on a 1:1 basis to receive either 1) an 8-week smoking cessation program that consisted of: 8 weeks of nicotine replacement therapy (NRT) gum, a written self-help guide with information about quitting smoking, 4 sessions with a trained counselor, and WeChat-based messaging (Quit for Life intervention group), or 2) NRT gum and written self-help guide only (Control group). Our 1:1 randomization scheme was constructed by a biostatistician using dedicated software (SPSS v. 25, New York, USA), with study groups assigned in sealed envelopes. This pilot study was not powered to detect minimal clinically meaningful differences between groups with statistical significance as the resulting estimates are imprecise and difficult to apply to sample size estimation in future trials.[20] Our sample size was chosen to provide a sufficient basis to evaluate feasibility and acceptability and exceeds the median sample size estimates from a review of other pilot studies with dichotomous outcomes.[21] Study procedures were approved by the Institutional Review Boards of Boston University Medical Campus and the Guangxi Medical University. The ClinicalTrials.gov identifier is: NCT05020899; date of trial registration was: 8-19-2021 (https://clinicaltrials.gov/study/NCT05020899)

Participants and procedures

Recruitment occurred by approaching individuals in person during their appointment at the HIV clinic of the Fourth People’s Hospital of Nanning, Guangxi, China. Guangxi Zhuang Autonomous Region (Guangxi) is located in the Southwest region of China. In 2018, Guangxi reported more than 50,000 HIV cases in one year, ranking it third highest for number of incident HIV cases among all provinces in China.[22] Starting in 2003, the Chinese government began providing free ART and HIV prevention services to encourage individuals to participate in screening and treatment.[22] The Fourth People’s Hospital of Nanning is the only Grade A (the highest classification) tertiary infectious disease hospital (comprehensive, referral hospitals) in Nanning city.

Eligibility criteria were being HIV seropositive and receiving ART treatment at the HIV clinic and smoking ≥5 cigarettes/day (i.e., more than light smoking[23]), able to speak and read in Mandarin Chinese, anticipate to continue receiving ART from the clinic for at least the 9 subsequent months, owning a cell phone, and willing to set a quit date within 1 month after baseline assessment. Exclusion criteria were self-reported use of another smoking cessation program or medication; or having a serious health problem rendering the individual unsuitable for participation. A Research Assistant conducted screening in person, after which eligible participants completed the informed consent process and the in-person baseline study visit consisting of a self-administered baseline survey, followed by randomization. Baseline data collection occurred between February 2022 to April 2023 and ended when the target sample size was reached. In-person follow-up assessments occurred 8 weeks (end of treatment) and 12 weeks post-baseline. Research assistants inputted data from paper surveys directly into a software platform (EpiData)[24]. Surveys were entered in duplicate and checked for errors. Participants received ¥200 Chinese Yuan (i.e., ¥50 at baseline, ¥50 at 8-week, and ¥100 at the completion of all 12-week assessment activities), corresponding to about USD 28 at the time of this study.

Study groups

Quit for Life intervention group

After baseline data collection, participants randomized to the intervention group were provided an 8-week smoking cessation program (Table 1) consisting of 4 components: 1) an offer of an 8-week supply of NRT gum; 2) printed 24-page self-help quitting smoking guide; 3) 4 sessions with a trained counselor; and 4) WeChat-based messaging. All components were delivered in Mandarin Chinese. The Quit for Life intervention content was informed by our qualitative formative research in which participants discussed influences on their smoking behavior and relationships between smoking and HIV.[18]

Table 1.

Intervention components of the 8 week Quit for Life smoking cessation program for PWH from China

Intervention Component Description
1. NRT gum • Participants asked if they are willing to use NRT gum to help them quit smoking
• Those who accepted were provided with a 8 week supply of 2 or 4mg NRT gum, usage instructions, and instructions on how to buy more (at participant’s cost) if desired after 8 weeks
2. Self-help quitting smoking guide • 24-page printed educational guide
• Produced in 2018 by the Tobacco Control Office at the Chinese Center for Disease Control and Prevention
• Topics: information about addiction, risks of smoking, benefits of quitting, preparing for quitting, quitting resources, dealing with challenging situations, dealing with relapse, and staying smoke free
3. Sessions with a trained counselor • The behavioral counseling was conducted by two nurses, each with at least one year of experience in HIV outpatient services
• Three-and-a-half-day training over two weeks, provided by Professor Yuan Jiang former director of the Tobacco Control Office at the China Center for Disease Control and Prevention. Training included in-person and online teaching, demonstrations, video learning, and role-playing about research ethics, smoking cessation techniques, and intervention skills. Refresher training conducted after 1 year.
• Followed written counseling session guide. 4 sessions: Session 1 is in-person (~20 minutes), Sessions 2 through 4 are over the telephone (~15 minutes/session)
• Sessions occurred at baseline, 1 week, 4 weeks, and 8 weeks
• Session 1 topics: review of smoking history, lifestyle/barriers to quitting, discussion of harmful effects of smoking (including smoking and HIV), discussion of benefits of quitting, assessment of motivational readiness to quit, address barriers, formulate treatment plan)
• Sessions 2–4 topics: check in about WeChat-based messaging, check in about smoking pattern since last session, discuss NRT usage, note withdrawal symptoms, address problems, discuss actions to maintain quit status or encourage quitting)
• Feedback provided on one call transcript for quality assurance, as most participants did not agree to audio recording
4. WeChat-based messaging • Schedule: 3 messages/day during week 1; 2 messages/day during weeks 2–4; 1 message/day during week 5; and 2 messages/week during weeks 6–8
• Mean (range) number of Chinese characters: 56.8 (15–108)
• Original message library was based on NCI SmokeFree Text program, and then modified for Chinese context based on qualitative focus group feedback.[46] Next, we used a separate round of formative research to further modify the library for Chinese PWH[18]
• Messages were one-way (i.e., not interactive) and complemented the topics of the counseling sessions
• Example messages (messages below are presented in English; but were delivered to participants in Chinese):
  • When you are stressed, anxious or depressed, it is a good idea to take a short break. A short break will help you think more clearly and help you calm down. It also can help you to make the right decision for your next step in quitting
  • Tired and stressed from working? If you can take a break, try taking a walk. Take a deep breath of the air without nicotine. When you are walking, reflect on the reasons that you decided to quit and appreciate your effort in quitting
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Control group

Participants received NRT gum and the self-help quitting smoking guide (Table 1) and no other intervention components, as customary at the HIV clinic.

Measures

Survey instruments developed or validated in Chinese were used when available[25–29]; otherwise, instruments in English were translated to Chinese by research team members with native fluency.

Socio-demographics and other variables

At baseline, we assessed age, gender, and other socio-demographic variables. We also measured the Fagerstrom Score of nicotine dependence[25,30], Berger’s 18-item HIV stigma scale,[26] 14-item perceived stress scale,[27,28] and depressive symptoms via the CES-D.[31]

Efficacy on smoking cessation

Expired air carbon monoxide testing (CO Check Pro, MD Diagnostics Ltd. England) was used to biochemically measure smoking status at 12-week follow-up (primary outcome); readings <8 parts per million (p.p.m.) were coded as ‘abstinence’ and readings ≥8 p.p.m. were coded as ‘smoking’.[32] Change in the self-report of not smoking during the previous 7 days (7-day point prevalence abstinence) was measured at 8- and 12-weeks and was a secondary outcome.

Secondary outcomes

Additional secondary outcomes were change in number of cigarettes smoked in the last 30 days, number of quit attempts, ART adherence (investigator developed question assessing degree of adherence to taking HIV medicine on time measured on a scale of 0 “never on time” to 10 “always on time”) measured at 8- and 12-weeks and quality of life [29] (Quality of Life Index Value along five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression, which demonstrated good internal consistency reliability (Standardized Cronbach’s Alpha = 0.85); plus a visual analog scale of health state) measured at 12-weeks.

Intervention implementation

We assessed the frequency of completed intervention components (Table 1).

Intervention acceptability

Using a questionnaire at both 8- and 12-week assessments adapted from a prior study[33], intervention satisfaction was assessed by participants reporting on perceived ability to meet personal goals related to quitting smoking. Intervention group participants also reported on additional program acceptability metrics.

Statistical analysis

Baseline socio-demographic variables were summarized according to study group. We compared baseline characteristics between those with and without the primary outcome and found no significant differences between the groups. Therefore, we conducted a complete case analysis. Unadjusted and adjusted logistic regression was used to compare treatment groups for binary outcomes smoking cessation, quit attempts, satisfaction at meeting goals, ART adherence (dichotomized at 10 vs. less than 10), Quality of Life Index Value (dichotomized at 1 (high quality of life) vs. less than 1), and self-report smoking point prevalence. Unadjusted and adjusted comparisons between groups for continuous outcomes: smoking quantity change, and Quality of Life visual analog scale were made using linear regression models. Assumptions of linear regression were evaluated through visual inspection of Q-Q plots and histograms of residuals. Based on a literature review of variables conceptually linked to smoking cessation, models were adjusted for demographic characteristics age and education, and for Fagerstrom score at baseline.[34] Following the complete case analysis, we conducted a sensitivity analysis including all randomized participants regardless of their level of compliance with the intervention; missing primary outcome data was considered as smoking. Patterns of statistical significance were unchanged between the complete case and the sensitivity analyses; therefore, we present the complete case analysis findings. We conducted another sensitivity analysis using a lower commonly accepted smoking cessation threshold (readings <6 p.p.m. were coded as ‘abstinence’). [32] Statistical analyses were conducted using SAS version 9.4. The analysis plan was registered on clinicaltrials.gov (https://clinicaltrials.gov/study/NCT05020899).

RESULTS

We enrolled a total of 109 participants, 54 randomized to the intervention group, and 55 to the control group (Figure 1). Overall, 98 participants completed the 12-week assessment (89.9% retention rate). Baseline characteristics are presented in Table 2. Reflecting the population of PWH in China who smoke, the mean age at baseline was 45 years, the majority were men (96%), with less than a high school educational attainment (68%), working (57%), and reporting bad or very bad self-rated health (61%). At baseline, 9% were highly dependent, and 56% were moderately dependent on nicotine based on their Fagerstrom scores. The mean (SD) quality of life from the visual analog scale was 72.7 (16.1), from a scale of 0 (worst health) to 100 (best health), and 65% of the sample reported elevated depressive symptoms (CESD score ≥ 16). At 12-week follow up, mean carbon monoxide (CO) levels were 7.8 (range: 2.0–20.0) in the intervention group and 11.9 (range: 3.0–26.0) in the control group.

Figure 1.

Figure 1.

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Study Flow Diagram

a Participants could have more than 1 reason for exclusion

Table 2.

Baseline sample characteristics for participants in the Quit for Life pilot and feasibility trial

Study Group
Question Response Overall
(n = 109)		 Control
(n = 55)		 Treatment
(n = 54)
Age Mean (SD) 45.3 (15.1) 46.3 (15.8) 44.2 (14.5)
Gender Man 105 (96.3%) 53 (96.4%) 52 (96.3%)
Woman 4 (3.7%) 2 (3.6%) 2 (3.7%)
Marital status Single 37 (33.9%) 22 (40.0%) 15 (27.8%)
Married 54 (49.5%) 27 (49.1%) 27 (50.0%)
Other 18 (16.5%) 6 (10.9%) 12 (22.2%)
Education Less than high school 74 (67.9%) 37 (67.3%) 37 (68.5%)
High school graduate/GED 15 (13.8%) 8 (14.5%) 7 (13.0%)
Technical school or college 20 (18.3%) 10 (18.2%) 10 (18.5%)
Occupation Work 62 (56.9%) 30 (54.5%) 32 (59.3%)
Going to school 4 (3.7%) 3 (5.5%) 1 (1.9%)
Not working or unstable 43 (39.4%) 22 (40.0%) 21 (38.9%)
Difficulty paying monthly bills (Financial strain) Slightly or not at all difficult 87 (79.8%) 45 (81.8%) 42 (77.8%)
Somewhat difficult 18 (16.5%) 9 (16.4%) 9 (16.7%)
Very or extremely difficulty 4 (3.7%) 1 (1.8%) 3 (5.6%)
Self-rated health Good or very good 43 (39.4%) 25 (45.5%) 18 (33.3%)
Bad or very bad 66 (60.6%) 30 (54.5%) 36 (66.7%)
Nicotine dependence level Minimally dependent 38 (34.9%) 17 (30.9%) 21 (38.9%)
Moderately dependent 61 (56.0%) 32 (58.2%) 29 (53.7%)
Highly dependent 10 (9.2%) 6 (10.9%) 4 (7.4%)
Perceived stress level Mean (SD) 21.1 (8.0) 21.7 (8.0) 20.6 (8.1)
HIV Stigma Scale Mean (SD) 51.6 (9.9) 52.5 (10.4) 50.7 (9.4)
Quality of Life index score Mean (SD) 0.92 (0.10) 0.93 (0.09) 0.91 (0.10)
Depression score Mean (SD) 19.7 (9.0) 20.1 (7.0) 19.4 (10.7)
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Efficacy on smoking cessation

At 12-week follow-up, the biochemically verified smoking cessation rate (primary outcome) was significantly higher in the intervention group compared to the control group (59.1% abstinence vs. 25.6%, adjusted odds ratio (AOR (95% CI; wald Chi-Square)) 5.3 (1.5, 19.2; 6.6)) (Table 3).

Table 3.

Evaluation of the Quit for Life pilot trial on primary and secondary smoking cessation outcomes, complete case analysis

Outcome Overall Control Intervention Unadjusted OR (95% CI; Wald Chi-square) Adjusted OR (95% CI; Wald Chi-square)a
Biochemically verified smoking cessation (12-week) (primary outcome)
 Abstinence (<8 p.p.m.) 36 (43.4%) 10 (25.6%) 26 (59.1%) 4.2 (1.6,10.7; 9.0) 5.3 (1.5,19.2; 6.6)
 Smoking (≥8 p.p.m.) 47 (56.6%) 29 (74.4%) 18 (40.9%) -- --
Biochemically verified smoking cessation (12-week)
 Abstinence (<6 p.p.m.) 23 (27.7%) 4 (10.3%) 19 (43.2%) 6.6 (2.0,21.9; 9.7) 6.7 (1.7,26.4; 7.5)
 Smoking (≥6 p.p.m.) 60 (72.3%) 35 (89.7%) 25 (56.8%) -- --
Self-reported 7-day point prevalence abstinence (12-week) b
 Abstinence 29 (29.6%) 8 (16.7%) 21 (42.0%) 3.6 (1.4,9.3; 7.1) 4.1 (1.4,12.3; 6.4)
 Smoking 69 (70.4%) 40 (83.3%) 29 (58.0%) -- --
Self-reported 7-day point prevalence abstinence (8-week) b
 Abstinence 34 (34.0%) 12 (24.5%) 22 (43.1%) 2.3 (1.0,5.5; 3.8) 2.4 (0.9,6.3; 3.0)
 Smoking 66 (66.0%) 37 (75.5%) 29 (56.9%) -- --
Quit attempts (12-week)
 1 or more attempts 87 (88.8%) 38 (79.2%) 49 (98.0%) 12.9 (1.6,105.2; 5.7) 12.8 (1.5,107.1; 5.6)
 No attempts 11 (11.2%) 10 (20.8%) 1 (2.0%) -- --
Quit attempts (8-week)
 1 or more attempts 80 (80.0%) 36 (73.5%) 44 (86.3%) 2.3 (0.8,6.3; 2.5) 2.5 (0.8,7.5; 2.7)
 No attempts 20 (20.0%) 13 (26.5%) 7 (13.7%) -- --
Intervention satisfaction (12-week)
 Met all of your goal 29 (29.6%) 8 (16.7%) 21 (42.0%) 3.6 (1.4,9.3; 7.1) 4.8 (1.5,15.2; 6.9)
 Met some/none of your goal 69 (70.4%) 40 (83.3%) 29 (58.0%) -- --
Intervention satisfaction (8-week)
 Met all of your goal 28 (28.0%) 11 (22.4%) 17 (33.3%) 1.7 (0.7,4.2; 1.5) 1.5 (0.6,3.9; 0.7)
 Met some/none of your goal 72 (72.0%) 38 (77.6%) 34 (66.7%)
Quality of Life Index Value
 1 (high quality of life) 62 (63.3%) 29 (60.4%) 33 (66.0%) 1.3 (0.6,2.9; 0.3) 1.2 (0.5,2.8; 0.1)
 < 1 36 (36.7%) 19 (39.6%) 17 (34.0%)
ART Adherenced (12-week)
 10 60 (62.5%) 25 (54.3%) 35 (70.0%) 2.0 (0.8,4.5; 2.5) 2.1 (0.9,5.0; 2.8)
 <10 36 (37.5%) 21 (45.7%) 15 (30.0%)
ART Adherenced (8-week)
 10 67 (67.7%) 31 (64.6%) 36 (70.6%) 1.3 (0.6,3.1; 0.4) 1.6 (0.6,3.9; 0.9)
 <10 32 (32.3%) 17 (35.4%) 15 (29.4%)
Overall
N, mean (std) 		Control
N, mean (std) 		Intervention
N, mean (std) 		Unadjusted Mean Difference (95% CI; Wald Chi-square) Adjusted Mean Difference (95% CI; Wald Chi-square) a
Smoking quantity changec (12-week) 64, −198.8 (214.0) 38, −191.8 (175.4) 26, −208.8 (263.9) −17.0
(−122.8,88.8; 0.1)		 −30.4
(−129.3,68.6; 0.4)
Smoking quantity changec (8-week) 64, −170.2 (224.1) 36, −170.8 (163.7) 28, −169.3 (287.1) 1.5
(−108.2, 111.3; 0.0)		 −23.1
(−123.9,77.7; 0.2)
Quality of life – visual analog scalee (12-week) 98, 81.9 (10.0) 48, 79.8 (9.9) 50, 83.9 (9.8) 4.2 (0.3,8.0; 4.4) 3.7
(−0.2,7.5; 3.5)
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a

All models adjusted for: age, education, and baseline Fagerstrom Score

b

12 and 8-week self-report PPA: abstinence = self-reported smoking no cigarettes in the past 7 days

c

Smoking quantity change measured as the difference in cigarettes smoked from baseline to follow-up, with a negative value meaning fewer cigarettes were smoked at follow-up than at baseline

d

ART= Antiretroviral Medication Therapy, defined as degree to which ART medicine is taken on time on a scale of 0 “never on time” to 10 “always on time”

e

Quality of Life visual analog scale (“how good or bad is your health”, measured on a scale of 0 “worst health you can imagine” - 100 “best health you can imagine”)

Secondary outcomes

At 12-week follow-up, there were statistically significant differences between the intervention and control groups for rates of self-reported seven-day point prevalence abstinence (42.0% vs. 16.7%, AOR 4.1 (1.4,12.3; 6.4)), 1 or more quit attempts (98.0% vs. 79.2%, AOR 12.8 (1.5,107.1; 5.6)), and intervention satisfaction (meeting all your goals: 42.0% vs. 16.7%, AOR 4.8 (1.5,15.2; 6.9)). There were no statistically significant differences between intervention and control groups for smoking quantity change (adjusted mean difference −30.4 (CI: −129.3,68.6; 0.4)), ART adherence (AOR 2.1 (0.9, 5.0; 2.8)), or quality of life measures ((AOR 1.2 (0.5, 2.8; 0.1)) for QOL index value and adjusted mean difference 3.7 (−0.2, 7.5; 3.5) for the QOL analog scale). At 8-weeks, there were no statistically significant differences in self-reported 7-day point prevalence abstinence (AOR 2.4 (0.9, 6.3; 3.0)), quit attempts (AOR 2.5 (0.8,7.5; 2.7)), intervention satisfaction (AOR 1.5 (0.6, 3.9; 0.7)), ART adherence (AOR 1.6 (0.6, 3.9; 0.9)) or smoking quantity change (adjusted mean difference −23.1 (−123.9, 77.7; 0.2)). (Table 3)

Intervention implementation

In total, 61.5% of participants (45.5% in the control group, 77.8% in the treatment group) accepted the offer of NRT gum. 100% of participants received the self-help manual. Among those in the intervention group, of 4 total counseling sessions, a mean of 3.9 (SD=0.5) were completed, with 90.7% (49/54) completing all 4 sessions. Intervention participants received a mean of 71.6 (SD=14.5) WeChat-based messages, with 90.7% receiving all 76 messages.

Quit for Life intervention acceptability

For those in the intervention group, at 12-weeks, participants indicated the number of WeChat messages was ‘just right’ (73.5%) or ‘too many’ (12.2%) and usefulness of the WeChat messages (mean 5.2, SD=1.4) and counseling sessions (mean 5.6, SD=1.3, both on a scale of 1-not at all useful to 7-very useful). More participants in the intervention group indicated they would be very likely to recommend this program to others if it was offered again in the future compared to the control group (60.0% vs. 37.5%, p=0.04 (Fisher’s exact test)).

DISCUSSION

We found this smoking cessation intervention called Quit for Life consisting of provision of NRT, a quitting smoking guide, behavioral counseling, and WeChat-based messaging, among PWH in China to be feasible, acceptable, and demonstrated efficacy for smoking cessation when compared to a control group. Approximately 80% of eligible participants chose to enroll in the trial. While future studies should aim to increase the enrollment rate, our rate is similar to that of the China National Tobacco Cessation Cohort Study, a large ongoing nationwide multicenter prospective cohort intervention study with nearly 3,000 participants.[35] Our sample was comprised of people who face socioeconomic disadvantage and vulnerability as evidenced by 40% not working in a stable occupation, 1/5 with some or more difficulty paying bills, 2/3 with less than high school education attainment, and bad or very bad self-rated health (60%). HIV stigma scores, stress, and depressive symptoms scores among Quit for Life trial participants were in the moderate range. Yuan and colleagues found significant longitudinal relationships between perceived social support, internalized HIV stigma, and depressive symptoms among Chinese PWH.[36] Similar relationships between HIV stigma and psychosocial distress was also reported by Zhang and colleagues,[37] particularly among individuals in the age range of 35–49 years who reported the highest levels of depression and anxiety compared with younger or older age groups. Given these relationships in an age range representative of our sample, future interventions should consider targeting and strengthening social support in combination with evidenced based smoking cessation strategies to address smoking behavior as well as HIV stigma and mental health.[38]

The Quit for Life intervention was delivered as intended and achieved sufficient levels of participant-perceived acceptability in terms of usefulness, meeting personal goals, and recommending the program to others. Approximately 40% of participants did not accept the offer of a free 8-week supply of NRT gum. This is likely reflective of the low availability and use of NRT in China and mistrust of medications that can be purchased online[35] and indicates the need to combine the Quit for Life intervention with components increasing the acceptability of NRT. Its use has been low in China: over two rounds (2011, 2016) of the global adult tobacco survey in China, NRT use during a quit attempt was 2.5% in 2011 and 5.0% in 2016.[39] Medications such as varenicline and cytisine, although not found to provide additional benefit to NRT among PWH with risky drinking in Russia, might warrant consideration for PWH who smoke in China.[40] Future policy-related initiatives in China should focus on not only increasing acceptance and availability of NRT, but all evidenced-based smoking cessation resources, a long-standing tenant of HIV-care guidelines and tobacco control plans in LMICs[41,42] and China specifically.[43]

The Quit for Life intervention, in spite of its rather small sample size, demonstrated efficacy for smoking cessation. Those in the Quit for Life intervention group were significantly more likely to have biochemically verified smoking cessation compared to the control group at 12-week follow up (59.1% abstinence vs. 25.6% abstinence). Notably, the percentage of participants self-reporting 7-day point prevalence abstinence from smoking was higher than the percentage of participants with biochemically verified smoking cessation at the 6 p.p.m. level (29.6% vs. 27.7%), which was largely driven by those in the control group (16.7% vs. 10.3%). This phenomenon is reflective of similar rates of incongruence observed in other multi-site trials[44] using in-person and remotely obtained biochemical confirmation and in a meta-analysis[45] of remotely obtained biochemical confirmation. The reasons behind the incongruence are not well understood, but may be related to the desire to avoid the stigma of continued smoking which may be particularly acute among PWH who smoke in China. This is an area for future research, especially suited for qualitative methods for in-depth exploration.

Quit for Life featured WeChat-based messaging that was rated as useful by participants and were targeted to the concerns of PWH who smoke in China expressed during our formative research.[18] Even though our messaging program lacked more advanced features of other health technology programs for smoking cessation programs in China such as two-way messaging, individual personalization, availability for on-demand support, and sending of multimedia images, emojis, and voice messages[14–17], the simple messaging platform is relatively easy to scale up. Integration of additional features may increase the appeal and effectiveness of this component of Quit for Life even further and may transform the WeChat messaging into a stand-alone smoking cessation intervention. Acceptability of specific messages could also be assessed during implementation. In future studies, the WeChat messaging system could be tested with or without behavioral counseling, to determine whether the time and cost associated with counseling is needed to effectively address smoking among PWH in China, a vulnerable group who face socioeconomic disadvantage and vulnerability and other chronic health conditions.

Limitations of this study include limited geographic representation, as all participants were recruited from one hospital and potential selection bias resulting from eligible participants who chose not to enroll. Secondly, the 12-week follow-up may not adequately capture long-term smoking cessation outcomes. A longer period, such as 6 or 12 months, could provide more reliable data on sustained abstinence. Additionally, usage of NRT beyond acceptance of NRT at baseline was not assessed; future studies should track usage to provide insights into the mechanisms of action. Finally, the study has a gender imbalance limitation: with 96.3% male participants, the study’s generalizability to female HIV patients who smoke is limited. This imbalance may overlook gender-specific factors in smoking cessation, potentially affecting the applicability of findings to women with HIV.

Conclusion

The Quit for Life randomized controlled pilot intervention trial demonstrated sufficient feasibility, acceptability, and efficacy for smoking cessation among a sample of PWH in China who face socioeconomic disadvantage and vulnerability. Future directions of this work include strengthening the intervention platform via integration of social support features and a more robust messaging system and evaluation among a larger sample with greater geographic coverage to improve external generalizability.

Primary funding

This work was supported by grant R21CA243835 from the National Cancer Institute (NCI) (Lisa Quintiliani).

Footnotes

Competing interests

The authors have no relevant financial or non-financial interests to disclose.

Ethics Approval

This study was performed in line with the principles of the Declaration of Helsinki. Study procedures were approved by the Institutional Review Boards of Boston University Medical Campus and the Guangxi Medical University. Informed consent was obtained from all subjects.

The content is solely the responsibility of the authors and does not necessarily represent official views of the National Institutes of Health or other funding agencies. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Clinical trial registration details

Trial registration number: ClinicalTrials.gov Identifier: NCT05020899

Date of trial registration: 8-19-2021

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